care plan help..please!!

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hello! i'm working on my care plan right now and my patient this week has CAD and underwent percutaneous transluminal coronary angioplasty. anyway, there's a part in my care plan where i have to "list 3 potential research or inquiry questions you found regarding care of the patient/family." i do not know what's wrong with me right now, but my brain is not working and i cannot think of anything to write for this. i was just wondering if anyone could please help me out with this? i would appreciate any sort of input or help. thank you in advance! have a wonderful day!

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Specializes in Urgent Care.

Hmm..

What does the patient know about modifiable risk factors for CAD?

What is the success rate of angioplasty and how long before it reoccludes ?

What is the % of angioplasties that require stents?

What does the pt know about his/her medications?

is that what they are looking for?

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Specializes in intro nursing.

hi I need help with my care i finished it already but my professor told me that i have to make some changes in it but i do not know what i did wrong.

Case Study #4

Cardiac Problems

______________________________________________________________________________

Case Scenario:

Mr. John Jamison exertion (“I get so out breath when I walk to the corner of our

street”), fatigue, a dry, hacking cough, and sudden swelling in his feet. He states, “I had

an eight pound weight gain overnight”. He has a history of hypertension with poor

control, despite taking atenolol 10mb every day (q.d.). Upon physical exam, Mr

Jamison is tachycardic with an S3 gallop, and has expiratory crackles in the bases of

both lung. His feet and ankles have 3+ pitting edema. His vital signs are T= 98.2, P = 112,

R = 26, BP = 154/108. Mr. Jamison lives with his wife at home and “takes care of

her because she has had several mild strokes”. He states that they have one adult child

in the area, who comes to visit them every week. And, Mr. Jamison states that they

have live in the area of over 30 years and consequently have many friends in the

nearby region.

His laboratory and diagnostic results are:

Sodium: 142 mEq/L

Potassium: 3.9 mEq/L

Chloride: 100 mEq/L

Creatinine: 1.0 mg/dl

BUN: 15 mg/dl

Hgb: 15.0 g/dl

TSH: 2.5 uU/ml

Chest x-ray: left ventricular hypertrophy

ECG: normal sinus rhythm., age 67, comes to his primary care provider complaining of dyspnea with mild

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Specializes in med/surg, telemetry, IV therapy, mgmt.
hi I need help with my care i finished it already but my professor told me that i have to make some changes in it but i do not know what i did wrong.

Where's your care plan and the professor's comment's? All you posted was the information about the case scenario. I can't tell you where you are making errors or explain them to you without that information.

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Specializes in intro nursing.
Where's your care plan and the professor's comment's? All you posted was the information about the case scenario. I can't tell you where you are making errors or explain them to you without that information.

Cardiac Problems

ASSESSMENT DATA

(Appropriate data to support nursing diagnosis, include subjective and objective data)

NURSING DIAGNOSIS

(Must include scientific rationale for the diagnosis, include references*)

PLANNING

I. Goals (include realistic short

and long term client-

centered goals)

A.Short Term

B.Long Term

II. Nursing Interventions

NURSING IMPLEMENTATION

(What actually was done, must include scientific rationale with references and delegation of tasks*)

EVALUATION

(Actual outcome of care and appropriate follow-up actions)

Objective

Subjective

O: Pulse: High 112

B/P: High 154/108

Tachycardic w/ S3 gallop

Hypertension

3+ pitting edema: feet

and ankles, eight pounds

gain.

S: Client reports:

Shortness of breath

Fatigue, dry, hacking

cough, swelling in feet.

Patient states

"I take care of my wife".

Decreased Cardiac output R/T left sided heart failure as evidenced by Systolic BP is >100.

Risk for Impaired tissue integrity R/T Edema as manifested by swelling in feet and ankle.

Scientific Rationale:

In addition to the increased risk of injury to the skin from edema, loss of perivascular collagen in the small vessels of the skin makes them more susceptible to damage.

Risk for Activity Intolerance R/T dyspnea upon exertion.

Scientific Rationale:

Response to activity can be evaluated by comparing preactivity BP, pulse and respiration with postactivity results. These in turn, are compared with recovery time. Pg 101

Risk for caregiver role strain R/T Patient sole caregiver of wife.

Scientific Rationale:

Respite and the sharing of care responsibilities are vitals to prevent the caregiver-care recipient dyad from becoming the center of the universe, with all others viewed as less competent or less essential.

STG: Patient will maintain adequate fluid volume and electrolyte balance as evidenced by vital signs by the end of the shift

LTG:

STG: Patient will exhibit decreased edema from his feet and ankle by day two

LTG: Client will demonstrate knowledge on proper dietary intake by discharge.

1.Monitor daily and weekly dietary intake of food and fluids.

2.Assess client's knowledge of diet, medications and the use of knee high stocking to reduce pressure on skin areas

3. Teach client to decrease salt intake by reading the labels for sodium content and by cooking without or minimal salt.

4.Teach client to plan weekly menu that provides protein.

5.Assess client's skin for redness and blanching.

STG: Clients will perform active range of motion (ROM) at least twice a day.

LTG: Client will progress activity by walking from his room to the nurse's station twice a shift.

1.Monitor client's response to activity

2.Assess client's BP, pulse, respiration

3.Assess client's capability for increased activity

4.Encourage gradual increases in activity and ambulation to prevent a sudden increase in cardiac workload.

5.Teach on how to control breathing for use during increased activity

STG: Client will relate a plan on how to continue social activities despite caregiving responsibilities by the end of the shift.

LTG: Client will establish a plan for weekly support before discharge.

1.Encourage client to accept offers of help.

2.Assist client to identify activities for which he desires assistance.

3.Encourage client to set realistic goals for self and wife.

4.Assist client with accessing informational and instrumental support

  • Pt fluid balance assessed by measuring input and output, Pt vital signs and weight were implemented by UPA.

  • Pt wore stocking to promote venous return and edema from ankle and feet.

  • Pt walked twice a shift from room to nurse's station without assistance with no complains of insufficient energy.

I

  • Assessed fluid balance and measured input and output and Vital signs in expected range.

  • Edema from feet and ankle not present.

  • Patient verbalizes having sufficient energy to complete desired activities.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

although you didn't list your professor's comments, i see major problems with your care plan. three of your diagnoses are absolutely incorrect and do not even reflect the assessment data. you diagnosed only one actual nursing problem; i found 4 actual nursing problems. probably 75% of this care plan needs to be totally re-written. i will not address the classification of subjective and objective data. you can do that. i am more concerned about how you are determining, critical thinking and diagnosing the nursing problems. we use the nursing process to do that.

  1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
    • a physical assessment of the patient
    • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
    • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
    • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.

[*]determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.

[*]planning (write measurable goals/outcomes and nursing interventions)

  • goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
    • improve the problem or remedy/cure it
    • stabilize it
    • support its deterioration

    [*]how to write goal statements: https://allnurses.com/forums/2509305-post158.html

    [*]interventions are of four types

    • assess/monitor/evaluate/observe (to evaluate the patient's condition)
      • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.

      [*]care/perform/provide/assist (performing actual patient care)

      [*]teach/educate/instruct/supervise (educating patient or caregiver)

      [*]manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met)

step 1 assessment - collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology [color=#003300]- i want you to look up everything you can find about congestive heart failure because when i read through the scenario that is what was screaming out to me that was going on with this patient. this guy is in serious trouble with his heart today. you need to know what the pathophysiology of chf is, its signs and symptoms, complications and how physicians treat it.

  • [color=#003300]history of hypertension with poor control, despite taking atenolol 10mb every day - a beta blocker and antihypertensive that also slows the sa node discharge and will slow the heart rate. one of its side effects is that it can cause congestive heart failure.

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data [color=#003300]- this is the list i compiled from the scenario

tachycardic

  • p = 112
  • s3 gallop
  • bp = 154/108
  • sudden swelling in his feet states, "i had an eight pound weight gain overnight"
  • feet and ankles have 3+ pitting edema
  • chest x-ray: left ventricular hypertrophy
  • comes to his primary care provider complaining of dyspnea
  • r = 26
  • expiratory crackles in the bases of both lung
  • a dry, hacking cough
  • exertion ("i get so out breath when i walk to the corner of our street")
  • fatigue
  • tsh: 2.5 uu/ml (2-10uu is normal)
  • "takes care of her because she has had several mild strokes" (wife)
  • have one adult child in the area, who comes to visit them every week
  • live in the area over 30 years and have many friends in the nearby region

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use

  1. decreased cardiac output r/t altered stroke volume secondary to cardiac congestion aeb tachycardia of 112, an s3 gallop, blood pressure of 154/108, sudden swelling of 3+ edema in his feet with pitting, chest x-ray that shows left ventricular hypertrophy and patient statement that "i had an eight pound weight gain overnight". (this are all symptoms of congestive heart failure which has resulted in altered stroke volume, one of the components of cardiac output. you can read about cardiac output and congestive heart failure on these websites:

[*]activity intolerance r/t imbalance between oxygen supply and demand aeb fatigue and statement by patient that on exertion "i get so out breath when i walk to the corner of our street". (this diagnosis is about the patient having signs and symptoms approaching or actually getting hypoxia, so your scientific rationale is to find references that list the signs and symptoms of oxygen deprivation and hypoxia. fatigue is a long-term effect of hypoxia to the tissues.)

[*]ineffective airway clearance r/t retained secretions aeb dyspnea with respiratory rate of 26, expiratory crackles in the bases of both lungs and a dry, hacking cough. (this is your basic mucus trapped in the lung that the patient can't cough out. either he is too tired or weak or there is so much gunk there it is overwhelming. check your textbook under respiratory problems or the merck manual. many times these secretions are just so thick they are hard for the patient to cough out.)

[*]anxiety r/t threat to role aeb statement that he "takes care of her [wife] because she has had several mild strokes". (this is worry about not being able to do his responsibility as a husband. for rationale on role performance you may need to look at erickson's developmental stages would be my suggestion: middle-age adult (generativity vs stagnation: seeks satisfaction through productivity in career, family, and civic interests); older adult (integrity vs despair: reviews life accomplishments, deals with loss and preparation for death))

for the scientific rationale to support the use of these diagnoses you can use the websites referenced. the online merck manual has a lot of good information on cardiac and respiratory subjects (http://www.merck.com/mrkshared/mmanual/sections.jsp). i've also included weblinks to nursing diagnosis pages for these diagnoses that have some explanations about the diagnoses as well as some suggestions for interventions. so, you have several places to go for rationales now.

remember that your nursing interventions must address the items following the "aeb" part of each nursing diagnostic statement. then, the goal for that particular diagnosis must be what you predict should happen as a result of your interventions being followed. it should all make sense when the diagnosis, interventions and goals are read together.

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